MISSOURI DEPARTMENT OF SOCIAL SERVICES

FAMILY SUPPORT DIVISION

PAYMENT AFFIDAVIT
INSTRUCTIONS
This form is a notarized statement from you, the custodial parent/custodian, about how much child support and/or
maintenance (also known as spousal support or alimony) the noncustodial parent paid directly to you. Direct
payments are payments the noncustodial parent gave you or mailed directly to you. This statement also provides the
Family Support Division’s (FSD’s) child support program with information on other offices that have collected support
for you, so the child support program can obtain payment records from those offices, if necessary. The child support
program needs this information to calculate the amount of past–due support, if any.
1. Please complete the information requested below by typing or writing answers in ink.
2. You must sign the back page of this affidavit in front of a notary public. Do not sign until you are in the presence
of the notary public, who must witness your signature. FSD child support offices provide free notary public
services for this affidavit. Visit http://dss.mo.gov/cse/child-support-offices.htm to find the nearest child support
office. Most banks also have notaries, but may charge a fee if you do not have an account.
3. You cannot use this affidavit to give credit for support amounts that you did not receive. By completing
this affidavit, you are stating that you received the amounts listed. If the noncustodial parent owes you an
amount that you do not want to collect, you may close your child support case or consult an attorney about filing
court documents to waive collection of all or part of the debt owed to you.
4. If you have any questions, please immediately contact the Customer Service Call Center, toll–free, at 1–866–
313–9960.
5. Return this completed affidavit by the due date shown below to:
Family Support Division
PO Box 6790
Jefferson City, MO 65102–6790
6. If you receive Temporary Assistance benefits and you do not return this affidavit on time, you may lose some of
your Temporary Assistance money. If you do not receive Temporary Assistance benefits and you do not return
this affidavit on time, we may close your child support case.
DATE
THIS COMPLETED AFFIDAVIT MUST BE NOTARIZED AND RETURNED ON OR BEFORE ►
AFFIDAVIT
COUNTY AND STATE OF ORDER COURT ORDER NUMBER IV–D CASE NUMBER

CUSTODIAL PARENT/CUSTODIAN NAME (PERSON ORDERED TO RECEIVE SUPPORT) NONCUSTODIAL PARENT NAME (PERSON ORDERED TO PAY SUPPORT)

PLEASE CHECK ALL BOXES THAT APPLY, PROVIDE ANY INFORMATION REQUESTED, SIGN THE BACK OF
THIS FORM IN FRONT OF A NOTARY PUBLIC AND RETURN IT TO THE FSD OFFICE SHOWN ABOVE.
 I have not received a support payment for the above–listed order since the order was entered.
 I received support payments for the above–listed order directly from the noncustodial parent. (If this box is
checked, you must list direct payment amounts on the back of this form.)
 I received support payments for the above–listed order from the Family Support Payment Center, Missouri
State Treasurer or the circuit clerk in the county where the order is filed.
 I received support payments for the above–listed order from another state’s child support payment office.
Please write as much information as you know about the other state’s payment office on the lines below (office
name, address, city, state, telephone number).
_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

OTHER PAYMENT INFORMATION YOU WISH TO PROVIDE TO THE CHILD SUPPORT PROGRAM:
_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

MO 886–0312 (9–14) (PLEASE TURN PAGE) CS–509A (Rev. 9–14)

INSTRUCTIONS FOR REPORTING DIRECT PAYMENTS:
1. Only complete payment information below to report support amounts you received directly from the noncustodial
parent since the order was entered. If you did not receive a support payment directly from the noncustodial
parent, skip the section below and sign the bottom of this form in the presence of a notary public.
2. If your direct payment history is longer than six years, please attach extra sheets (completed in ink or typed), and
have your signature notarized on the extra sheets.
3. Sign below in the presence of a notary public and return this affidavit to the Family Support Division, PO Box
6790, Jefferson City, MO 65102–6790.

YEAR ____________ YEAR ____________ YEAR ____________

CHILD CHILD CHILD
MAINTENANCE MAINTENANCE MAINTENANCE
SUPPORT SUPPORT SUPPORT
RECEIVED RECEIVED RECEIVED
RECEIVED RECEIVED RECEIVED
JAN JAN JAN
FEB FEB FEB
MAR MAR MAR
APR APR APR
MAY MAY MAY
JUN JUN JUN
JUL JULY JUL
AUG AUG AUG
SEP SEP SEP
OCT OCT OCT
NOV NOV NOV
DEC DEC DEC
TOTAL TOTAL TOTAL

YEAR ____________ YEAR ____________ YEAR ____________

CHILD CHILD CHILD
MAINTENANCE MAINTENANCE MAINTENANCE
SUPPORT SUPPORT SUPPORT
RECEIVED RECEIVED RECEIVED
RECEIVED RECEIVED RECEIVED
JAN JAN JAN
FEB FEB FEB
MAR MAR MAR
APR APR APR
MAY MAY MAY
JUN JUN JUN
JUL JUL JUL
AUG AUG AUG
SEP SEP SEP
OCT OCT OCT
NOV NOV NOV
DEC DEC DEC
TOTAL TOTAL TOTAL
SIGN HERE IN THE PRESENCE SIGNATURE OF CUSTODIAL PARENT/CUSTODIAN DATE

OF A NOTARY PUBLIC ►
NOTARY INFORMATION
NOTARY PUBLIC EMBOSSER SEAL STATE OF COUNTY (OR CITY OF ST. LOUIS)

SUBSCRIBED AND SWORN TO BEFORE ME, THIS USE RUBBER STAMP IN CLEAR AREA
BELOW
DAY OF YEAR

NOTARY PUBLIC SIGNATURE MY COMMISSION EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

MO 886–0312 (9–14) CS–509A (Rev. 9–14)